Phys Dx - Pregnant Patient

Front 1

*Major Causes of Maternal Death in the US

Back 1

-embolism (17%)
-HTN (12%)
-ectopic pregnancy (10%)
-hemorrhage (9%)
-stroke (8%)
-complications from anesthesia (7%)
-abortion related complications (5%)
-cardiomyopathy (4%)
-infection (3.5%)

Front 2

*What should you immediately consider ins any female of reproductive age with abdominal symptoms?

Back 2

PREGNANCY

Front 3

How long does fertilized ovum stay in fallopian tube? What does it divide (many times) to become?

Back 3

3 days...divides to become morula

Front 4

What happens if there is an obstruction in the fallopian tube?

Back 4

ovum attaches to lining of tube=ectopic pregnancy

Front 5

What does the morula become 6-8 days after fertilization (in normal pregnancy) and what happens next?

Back 5

morula becomes blastocyst, migrates to uterus, and implants into endometrium (endometrium then grows over blastocyst)

Front 6

What is the chorion?

Back 6

a combination of the trophoblast and mesoderm

Front 7

What does the chorion secrete?

Back 7

hCG

Front 8

What does hCG do?

Back 8

controls corpus luteum and inhibits pituitary gonadotropins

Front 9

What is chorionic villi (chorionic frondosum)?

Back 9

villi that sprout from chorion to give maximum area of contact with maternal blood

Front 10

When is functional placental circulation established?

Back 10

by days 17-18 gestation

Front 11

3 types of decidua

Back 11

1) decidua capularis
2) decidua basalis
3) decidua vera

Front 12

What is the decidua capularis?

Back 12

overlying endothelium that covers conceptus

Front 13

What is the decidua basalis?

Back 13

between blastocyst and myometrium

Front 14

What is the decidua vera?

Back 14

decidua of remaining endometrial cavity

Front 15

*Hormones of pregnancy (5)

Back 15

1) hCG
2) Human Placental Lactogen (hPL or hCS)
3) Human Chorionic Thyrotropin (hCT)
4) Adrenocorticotropic Hormone (ACTH)
5) Estrogens

Front 16

What is hCG?

Back 16

-one of the first hormones present (as early as day 8 after fertilization)
-maximal levels at about 60-70 days after fertilization, then decreases
-maintains corpus luteum during first 2 months of pregnancy until placental can produce enough progesterone

Front 17

What is human placental lactogen (hPL or hCS)?

Back 17

-human chorionic somatotropin
-"growth hormone" of pregnancy
-promotes lipolysis --> increased FFA
-provides energy for mom and source of nutrition for fetus

Front 18

What are the 5 boundaries of the pelvis cavity borders?

Back 18

1) above - brim
2) below - outlet
3) posterior - sacrum
4) anterior - pubic rami
5) lateral - sacrosciatic ligaments and ischial bones

Front 19

What is the brim of the pelvic cavity?

Back 19

inner sacral promontory to upper and inner borders of symphysis pubis

Front 20

What is the outlet of the pelvic cavity?

Back 20

lower and inner borders of symphysis pubis to end of sacrum or coccyx

Front 21

Fetal to maternal anatomy relationship: lie

Back 21

-relationship of the long axis of fetus to that of mother
-99% of full-term pregnancies are longitudinal (perpendicular, transverse)

Front 22

Fetal to maternal anatomy relationship: presentation

Back 22

-part of fetus in lower pole of uterus overlying pelvic brim (cephalic, vertical, breech)
-can be felt through cervix
-usually occipital fontanelle is "presenting part" (=vertex presentation)

Front 23

Fetal to maternal anatomy relationship: attitude/habitus

Back 23

-posture of fetus (flexion, deflexion, extension)

Front 24

Fetal to maternal anatomy relationship: position

Back 24

-relationship of an arbitrary chosen portion of the presenting part of the fetus to the maternal pelvis (see diagram of fetal maternal positions)
-vertex presentation: occiput (LOA, LOP, LOT, ROA, ROP, ROT)
-breech presentation: sacrum
-face presentation: chin (mentum)

Front 25

What is the most common positions?

Back 25

LOA (left occiput anterior)

Front 26

Fetal to maternal anatomy relationship: station

Back 26

-the level of descent of the presenting part of the fetus above or below the plane of the ischial spines
-ranges from -3 to +3 (baby's head outside vaginal opening) with 0 station being at the level of the ischial spines

Front 27

Fetal to maternal anatomy relationship: engagement

Back 27

-occurs when the widest diameter of the fetal presenting part has passed through the pelvic inlet

Front 28

What is the widest diameter in cephalic presentation?

Back 28

-biparietal diameter

Front 29

What is the widest diameter in breech presentation?

Back 29

-intertrochanteric

Front 30

What are the pelvic configurations based on?

Back 30

brim, midpelvis, and outlet

Front 31

What are the 4 types of pelvis configurations?

Back 31

1) gynecoid
2) anthropoid
3) android
4) platypelloid
(most women are a combination of the basic types)

Front 32

ROS: amenorrhea

Back 32

-from high levels of estrogen, progesterone, and hCG
-doesn't allow endometrium to slough off

Front 33

ROS: nausea +/- vomiting

Back 33

-"morning sickness" of pregnancy
-thought to be caused by high levels of hCG and estrogen
-hypersensitivity to odors/ altered taste

Front 34

What should you watch for with severe vomiting?

Back 34

-dehydration and ketosis; not common

Front 35

When does morning sickness usually improve?

Back 35

12-16 weeks when hCG falls

Front 36

ROS: breast changes

Back 36

-increased vascularity associated with sensation of heaviness (week 6)
-pigmentation of areola and nipple and nipple erect (week 8)
-further pigmentation and mottling by week 20

Front 37

What are montgomery tubercles?

Back 37

-raised, pinkish-red nodules on areola (more prominent during pregnancy)

Front 38

When is colostrum secreted and expressed from nipple?

Back 38

week 16

Front 39

ROS: respiratory changes

Back 39

-change in breathing from abdominal to costal
-shortening and widening at base of thoracic cage
-elevation of diaphragm
-increase in respiratory rate

Front 40

ROS: cardiovascular changes

Back 40

-displacement of apical impulse laterally 1.0-1.5 cm
-grade 2/6 systolic murmur
-increase in pulse rate; slight fall in BP in 2nd trimester

Front 41

ROS: abdominal changes

Back 41

-contour changes because of gravid uterus
-striae gravidarum
-decrease in muscle tone
-linea nigra
-reduced peristaltic activity

Front 42

ROS: heartburn

Back 42

-due to progesterone
-causes relaxation of GE sphincter (in 3rd trimester is due to pushing up of enlarged uterus --> decreased gastric motility and decreased gastric acid secretion)

Front 43

ROS: changes in musculoskeletal system

Back 43

-slight instability of pelvis
-alteration of standing posture and gait to compensate for gravid uterus

Front 44

ROS: backache

Back 44

-from estrogen and progesterone
-relaxation of pelvic joints
-increased uterine weight increases lordosis
-abdominal muscles stretch and lose tone

Front 45

ROS: quickening

Back 45

-sensation of fetal movement
-usually week 20 in primigravida (2-3 weeks earlier in multipara)

Front 46

ROS: disturbances in urination

Back 46

-start week 6 --> increased frequency
-as uterus rises above pelvis, symptoms remit
-near term symptoms recur as fetal head impinges on volume capacity of urinary bladder

Front 47

ROS: vaginal discharge

Back 47

-asymptomatic, milky, white discharge due to estrogen

Front 48

ROS: fatigue

Back 48

-very common, due to estrogen

Front 49

Skin changes in the pregnant patient: hyperpigmentation

Back 49

hyperpigmentation: especially in women w/ dark hair and dark skin
1) linea nigra: darkening of linea alba (midline streak on abdomen)
2) chloasma: cheeks, forehead, chin, nose

Front 50

3 other skins changes in the pregnant patient

Back 50

-striae gravidarum: irregular, linear, pink/purple lesions on abdomen, breast, upper arms, buttocks, thighs
-nails: transverse grooving, brittleness, softeness
-hirsutism: increased hair in face, arms, legs, back

Front 51

Risk assessment: age

Back 51

older women increased risk of chromosome abnormalities, trisomies

Front 52

Risk assessment: parity

Back 52

placenta previa, placenta accreta, postpartum hemorrhage and uterine rupture

Front 53

Risk assessment: height

Back 53

less than 5 feet=small pelvis=cephalopelvic disproportion (CPD) --> C section

Front 54

Risk assessment: underlying disease

Back 54

-DM, HTN, renal dz --> fetal intrauterine growth retardation (IUGR), premature labor, toxemia, abruptio placentae

Front 55

***What is the most common medical complication of pregnancy? How common is it?

Back 55

-diabetes
-occurs in 2-3% of all pregnancies

Front 56

Risk assessment: hemoglobinopathy

Back 56

-pregnancy can worsen anemia

Front 57

Risk assessment: isoimmunization

Back 57

-Rh negative --> hemolytic anemia

Front 58

Risk assessment: previous prematurity

Back 58

watch for incompetent cervix --> increased risk of premature delivery

Front 59

Risk assessment: infections

Back 59

-rubella/herpes
-do not deliver vaginally with active herpes
-if rubella negative, immunize after delivery (just before leaving hospital)

Front 60

Risk assessment: smoking

Back 60

-risk of IUGR and hypoxia during labor

Front 61

Risk assessment: drugs

Back 61

-spontaneous abortion
-addictions
-IUGR

Front 62

Risk assessment: alcohol

Back 62

-fetal alcohol syndrome

Front 63

What does GTPAL stand for?

Back 63

G: gravidity: total number of pregnancies (including current pregnancy)
T: total number of full-term births
P: number of pre-term births (21-37 weeks)
A: number of abortions (terminated at or before 20 weeks gestation)
L: number of living children

Front 64

Estimated Date of Confinement

Back 64

-use a "wheel"
-calculation
1) date of onset of LMP
2) subtract 3 months
3) add 1 year
4) add 7 days

Front 65

Nagele's Rule

Back 65

add 9 months and 7 days to the first day of the LMP

Front 66

*How long of a gestation period is Nagele's rule based on?

Back 66

280 days

Front 67

What should teeth and gums be inspected for?

Back 67

-bleeding, hyperplasia and gingivitis
-periodontal disease is common in pregnancy and associated with adverse outcomes
-tx during pregnancy is safe

Front 68

What happens to fibroadenomas and masses of the breast during pregnancy?

Back 68

they enlarge due to estrogen effect

Front 69

*Fundal height

Back 69

-top of symphysis pubis in straight line to top of fundus (w/ empty bladder
-betwen 18-32 weeks, fundal height in cm should be equal to number of weeks gestation (+/- 1 cm)

Front 70

Where is the uterus at 12 weeks, 20 weeks, and 36 weeks?

Back 70

-12 weeks: uterus enters abdmen
-20 weeks: uterus at umbilicus
-36 weeks: uterus just under costal margin

Front 71

*What is "lightening" of the abdomen?

Back 71

-decrease in fundal height weeks 38-40 from descent of fetus into pelvis --> "dropping"

Front 72

*What should fetal heart rate be? Where would heart rate be felt at weeks 12-18 and 30?

Back 72

-120-160 bpm
-weeks 12-18: HR heard midline of lower abdomen
-week 30: HR heard over fetal chest or back

Front 73

*How can lie and presentation of fetus be assessed?

Back 73

Leopold's maneuvers (week 28 on)

Front 74

Leopold's maneuvers: evaluate upper pole

Back 74

-defines fetal part in fundus
-palpate uterine fundus with fingers
-usually feel buttocks as firm but irregular
-breech --> head at upper pole- hard, round and usually movable

Front 75

Leopold's maneuvers: locate position of fetal back

Back 75

-palms on both sides of abdomen and gently apply pressure to uterus and feel back and limbs
-back is rounded, smooth and hard
-limbs are nodular or bumpy and may feel kicking

Front 76

Leopold's maneuvers: palpate lower pole of fetus

Back 76

-use thumb and fingers of one hand to grasp lower portion of maternal abdomen just about symphysis pubis
-if not engaged, feel movable part (usually head)
-if engaged, fetus is fixed in pelvis

Front 77

Leopold's maneuvers: confirm presenting portion and locate side of cephalic prominence

Back 77

-stand facing patient's feet
-hands on both sides of lower abdomen
-use tips of finger to apply deep pressure in direction of pelvic inlet
-if the presenting portion is the head and it is flexed, one hand will be stopped sooner by the cephalic prominence
-in vertex presentation, cephalic prominence on same side as limbs
-if in the vertex position with the head extended, the prominence is on the side of the back

Front 78

Speculum exam of pregnant patient

Back 78

-inspect cervix: should be dusky blue (week 6-8)
-note vaginal secretions, dilation, vaginal walls (blue and violaceous)

Front 79

*When should PAP test and GC/Chlamydia cultures be done?

Back 79

-on initial exam and repeat in 26 weeks

Front 80

What is the normal length of the cervix?

Back 80

1.5-2.0 cm; shortens and effaces in labor

Front 81

*What is Hegar's Sign?

Back 81

-softening of the isthmus of cervix
-feel fingers close together on bimanual exam (week 6-12)

Front 82

When can uterus be palpated abdominally?

Back 82

12-14 weeks

Front 83

When can fetal parts be palpated?

Back 83

26-28 weeks

Front 84

Is rectovaginal exam necessary?

Back 84

not unless patient has retroverted and retroflexed uterus

Front 85

***Bleeding during pregnancy

Back 85

-very common in pregnancy
-can be benign or pathologic

Front 86

First trimester bleeding

Back 86

-implantation of ovum, cervicitis, vaginal varicosities, abortion
1) threatened abortion
2) inevitable abortion
3) incomplete or complete abortion

Front 87

Threatened abortion

Back 87

-usually within first 20 weeks of pregnancy
-cervix closed, slight bleeding with or without cramping

Front 88

Inevitable abortion

Back 88

-presents during first half of pregnancy with bleeding and crampy abdominal pain associated with dilated cervix or gush of fluid (rupture of membranes) without passing products of conception

Front 89

Incomplete or complete abortion

Back 89

-passage of all or part of products of conception outside body

Front 90

Second or third trimester bleeding

Back 90

-60% from placenta previa (low lying placenta) or abruptio placentae: very serious condition
1) placenta previa
2) abruptio placentae
3) post-partum hemorrhage
4) vasa previa
5) pseudocyesis

Front 91

Placenta previa

Back 91

-1/200 deliveries
-more common in multiparous women
-abnormal location of placenta over or near internal os
-painless vaginal bleeding associated with soft, non-tender uterus
-increased risk of premature labor

Front 92

Abruptio placentae

Back 92

-separation of placenta after 20th week of gestation and before delivery
-sx: pain w/ or w/o external bleeding, increased uterine tone and tenderness
-higher the parity, the higher the risk
-common among AA women

Front 93

***What is the most commonly associated condition with abruptio placentae?

Back 93

HTN

Front 94

*What are 2 other habits associated with abruptio placentae?

Back 94

cigarette smoking and cocaine use

Front 95

***What is the MCC of serious bleeding and a leading cause of maternal death?

Back 95

post-partum hemorrhage (blood loss in excess of 500 mL during first 24 hrs after delivery)

Front 96

**What are the MCCs of post-partum hemorrhage?

Back 96

-uterine atony and laceration of the vagina/cervix

Front 97

Cause of uterine atony

Back 97

-complications of general anesthesia
-overdistention of uterus by a large fetus or twins
-prolonged labor
-rapid labor
-augmented labor
-high parity
-retained products of conception
-coagulation defects
-sepsis
-ruptured uterus
-chorioamnionitis
-drugs: ASA, NSAIDS

Front 98

Vasa previa

Back 98

-very rare and SERIOUS
-some of fetal vessels in membrane cross internal os
-can rupture with rupture of membranes causing fetal blood loss and possible exsanguination

Front 99

Pseudocyesis

Back 99

-false pregnancy
-1/5000 pregnancies
-have many of the classic symptoms of pregnancy
-may report fetal movement, weight gain, amenorrhea
-associated with psychosis and schizophrenia
-must see a psychiatrist

Front 100

***What is the name of Ursula's eels in "The Little Mermaid"?

Back 100

Flotsam and Jetsam!
(DEFINITELY a test question! Also, I'm anal and it was bothering me that I only made 99 flashcards so I added this one in to get to 100...just so ya know)